P - 42118Building
Inspections
763-572-3604
763-502-4�77 FAX
BUILDING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTNE 1-1-2011
Permit No.: �
Received By:;
DATE YOUR E-MAIL ADDRESS � I•� c,,. ,�lLt r E� 4-dd". i'► e-oL---
STTE ADDRESS �/ �i Z /-{ ,��� y.�
TT�TTS APPLTCANT IS: ❑ OWNET2 �ONTRACTOR
PROPERTY OWNER/ ��:
TENANT . ��.,.
CONTRACTOR
SUBMIT A COPY OF
YOUR STATE LICENSE
AND CET2TIFTCATE OF
TNSURANCE
PROPERTY TYPE
PT�ONE:
i _ a •
,. .
STATE�ZTP ✓-��
STATE LICENSE # ��% LEAD CERT NUMBER
.abb�ss: ,2 / �f G l L nu ,�. ' � crrY ��, �G,' ,�� sTArE�'irP �o t/
pr�o�'7l S -"S7�J- �19G'�
�STNCrT.E FAMTLY/NEW CONSTRUCTION
❑ TWO PAMILY/NEW CONSTRLTCTION
PERMIT TYPE � �DITTON ❑ GARAGE/SHED
O BASEMENT FTNTSH �ROOF
❑ DECK ❑ SIDING
❑ SWTMMING POOL
FAX �7Ci�i—�<1S7'—
SIZE
STORIES
❑ WINDOWS
❑ DRATN TII.E
❑ OTHER
TYPE OF WORK: I❑ NEW HOME CONSTRUCTION ❑ ADDITION
� MAINTENANCElREPAIIt ❑ REMODELING
DESCRTBB �71rORK BEING DONE: K �! �
YtOOFING
NLTMBEI2 OF SQUARES � "S—
GATtAGES
PROPOSED STZE:
PROPOSED T�TEIGTiT:
� HOUSE ONLY
❑ HOUSE 8t GARAGE
❑ ATTACHED GARAGE
,�DETACHED GARAGE
HETGHT
FT
BASEMEhTT REMObELTNG SY7BMTT:
1. Existing Floor Plan
2. Proposed floor plan
3. List of structural members to be used
SY�Y�� FOR I�T�VJ CONSTT2UCTTON INCLUDINCr DECTCS,
❑ Vinyl ❑Soffit ADDTTTONS. & PORCFiES SL7BMIT:
❑ Aluminum O Trim 1. Site Plau/Surveq showing the existing shvctures
❑ Other ❑ Fascia and proposed project.
2. Two sets of constivction plans
WINDOWS 3. Energy Calculations
IN EXTSTING OPENTNCrS ❑Yes ONo LOCATTON OF WINDOWS FOR WiNDOWS - PROVTDE I7-'VAT.,i7E AND
OTt FOTt NEW OPENiNGS-DESCRTB� SIZE OF MANiJFACTiiRE STICKER O1�I VJiNDOW.
OPENTNG CHANGES 8c
TYPE OP WTNbOW TO BE TNSTALLED NUMBER OF WINDOWS
ALL FEES ARE BASED ON VALUATION, INCLUDING THE COST OF LABOR AND MATERIALS:
(USING THE 1997 U.B.0 FEE SCHEDULE)
'OTAL JOB VALUATION $ OCCUPANCY TYPE
Permit Fee
1'lan Review
�'ire Surcharge
Surcharge
License Surcharge
SAC Charge
Curb Cut Escrow
�rosion Control
Park Fee
Sewer Main Charge
Total Dae
$ .�3�v��CU
$
�
$ .b
$ �D
$
$
$
$
$
$ '
See Back Page for Fee Schedule
65% of Building Permit Fee
.001 times the total job valuation
.0005 x Permit Valuation Minimum $5.00
$5.00 (State Licensed Residential Contractors)
$2230 per SAC Unit (Plans to MWCC for determination)
ft+6ft= ftx$25=$
$450 Conservation Plan Review
Fee Determined by Engineering
Agreement necessary ( ) Non Necessary ( )
Make checks payable to: City of Fridley Attach
THIS TS AN APPLICATTON FOR A PERMIT-NOT VALID iTNTIL PTtOCESSED
Y hereby apply for a building permit and I acknowledge that the informarion above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Conshvction Codes; that T understand this is not a
permit but only an application r a permit and work is not to start without a permit on site; that the work will be in accordance with the
approved plan in the case of � ' s review and approval of pl�,ttls„ �, r^ n� �A� �_27 —//
STCr2 TATLTRE OF APPLICANT PRINT NAME ��0�1�,_..f �-1�-, d/
APPROVAT. TI�TSPECTOR STG A